Section 405IAC5-21.6-7. Coverage requirements; limits

   (a) For an AMHH service to be reimbursable under this rule, the service must:

(1) be listed in this rule as a covered service;

(2) be habilitative in nature;

(3) promote member stability;

(4) demonstrate the member's movement toward the individual goals identified in the member's IICP; and

(5) continue to provide a benefit to the member.

  (b) The following services are covered under the AMHH services program according to the coverage criteria, limitations, and procedures specified in this rule:

(1) Adult day services.

(2) Home and community-based habilitation and support.

(3) Respite care.

(4) Therapy and behavioral support services.

(5) Addiction counseling (substance-related disorder).

(6) Peer support services.

(7) Supported community engagement services.

(8) Care coordination services.

(9) Medication training and support.

  (c) The following services will not be covered and are not eligible for reimbursement under this rule:

(1) A service provided to the member at the same time as another service that is the same in nature and scope, regardless of funding source, including federal, state, local, and private entities.

(2) A service that is provided while the member is in an institutional or noncommunity-based setting.

(3) A service provided as a diversionary, leisurely, or recreational activity that is not a component of an authorized respite care service.

(4) A service that is provided in a manner that is not within the scope or limitations of an AMHH service.

(5) A service that is not documented as a covered or approved service on the member's office-approved IICP.

(6) A service that is not supported by documentation in the member's clinical record.

(7) A service provided that exceeds the defined limits of the service, including service quantity, limits, duration, or frequency.

(8) An activity that is excluded from the service scope or definition.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.6-7; filed Dec 16, 2013, 9:11 a.m.: 20140115-IR-405130183FRA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA)